Sinus Surgery (Preauthorization Required)
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Defines Blue Cross Blue Shield of Nebraska coverage and preauthorization requirements for sinus surgery procedures (e.g., FESS, septoplasty, turbinate surgery) for plan providers and members.
Coverage and Medical Necessity
Medical necessity per MCG
Covered when ALL of the following are met:
Providers must use MCG criteria or contact umanagement@p3hp.org for coverage criteria or login assistance.
The Medical Policies contained in this document are developed by Blue Cross Blue Shield of Nebraska to assist in determining plan benefits. These policies are evidence-based guidance and do not constitute authorization, certification, or a contract for benefits. Benefits for a specific service are determined by the terms and conditions of the member's applicable benefit contract, and clinical review or prior authorization processes described elsewhere in this policy should be followed to determine eligibility.
This policy does not provide a discrete list of conditions labeled "not medically necessary." Instead, medical necessity for sinus surgery is determined by applying the referenced Milliman Healthcare Guidelines (MCG) clinical criteria. Providers should use the MCG criteria specified in the policy when requesting coverage determinations or contact the plan for assistance if they do not have access.
Procedure and Billing Codes
| 30140 | SUBMUCOUS RESECJ INFERIOR TURBINATE PRTL/COMPL |
| 30520 | SEPTOPLASTY/SUBMUCOUS RESECJ W/WO CARTILAGE GRF |
| 31253 | NASAL/SINUS NDSC TOT W/FRNT SINS EXPL TISS RMVL |
| 31254 | NASAL/SINUS ENDOSCOPY W/ETHMOIDECTOMY PARTIAL |
| 31255 | NASAL/SINUS ENDOSCOPY W/ETHMOIDECTOMY TOTAL |
| 31256 | NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY |
| 31257 | NASAL/SINUS NDSC TOTAL WITH SPHENOIDOTOMY |
| 31259 | NASAL/SINUS NDSC TOT W/SPHENDT W/SPHEN TISS RMVL |
| 31267 | NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS |
| 31276 | NASAL/SINUS NDSC W/FRONTAL SINUS EXPLORATION |
Provider Requirements and Authorization
Preauthorization required — submit procedure and diagnosis code pair
Preauthorization is required for sinus surgery procedures listed in this policy; providers must submit both the procedure (CPT) code and the associated diagnosis code pair when requesting authorization.
Conservative therapy expected prior to surgery
Surgery is indicated only after conservative medical management has been tried and failed; the policy describes sinus surgery as a treatment when medications and other treatments have not been effective.
- Document prior conservative therapy (medical management, medications, other non‑surgical treatments) and clinical response before authorization.
- Authorization requests should clearly state that conservative treatment was attempted and ineffective.
Use MCG criteria — contact for access
MCG clinical criteria are used to determine medical necessity for sinus surgery; if you do not have MCG login credentials or need the coverage criteria, contact umanagement@p3hp.org for access or assistance.
- Milliman Healthcare Guidelines (MCG) are the referenced criteria source.
- Email umanagement@p3hp.org to request coverage criteria or login help.
Confirm procedure/diagnosis code pairs to avoid denial or hold
Verify that the exact procedure + diagnosis code pair is listed in the policy—procedure/diagnosis pairs not entered or not listed may be denied or held for review.
- Use the policy Quick Code Search: enter the procedure code, then the diagnosis code, then click "Add Code Pair" to see approval status.
- If the code pair is not listed, the request may be denied or held for review.
Clinical Background
Functional endoscopic sinus surgery (FESS) is an endoscopic procedure performed through the nostrils using a thin scope to remove obstructing tissue, bone, or polyps to open sinus passages. Sinus surgery, most commonly FESS, is used to treat chronic sinus disease when medical management and other conservative treatments have failed, with the goal of restoring sinus drainage and airflow and improving symptoms and quality of life.
Key Definitions
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